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County Clerk and Recorder County Application PLEASE READ THESE INSTRUCTIONS CAREFULLY WHO CAN ORDER A DEATH CERTIFICATE? Complete copies of a certified death certificate will be issued to anyone who submits a completed application, establishes their identity, and lists the reason for needing the copy. If a death certificate lists the cause of death as "pending autopsy" or "pending investigation", a certified copy which has the cause of death information removed will be issued. IDENTIFICATION IS REQUIRED The person signing the request must provide an enlarged legible photocopy of both sides of their valid driver’s license or other legal picture identification with a signature or the requestor must have this application notarized. Suggested Identification Picture ID with a Signature OR Two Forms of ID – One MUST have a Signature OR • Driver’s License • State ID Card • Passport • Military ID Card • Tribal • Social Security Card • Work ID Card • Car registration/Insurance • Doctor/Medical record • Fishing License • US Military DD 214 • Utility Bill with a current address • Voter Registration Card • Credit/Debit/ATM Card • School ID Card • Library Card • Insurance Record • Pay Stub • Traffic/ Pawn ticket • Court record • Year Book • Notarized Montana Office of Vital Statistics Statement to Identify certified Birth or Death Certificate Applicant form (you must provide the original letter, not a photocopy or faxed copy) • Have an authorized family member that has an ID order the certificate If a picture ID with a signature is not available, two other forms of identification are required; one MUST have a signature. Please include photocopies of both sides of the ID when mailing your request IMPORTANT: If the identification requirement is NOT met or if the application is incomplete, your request will be returned and significant delays in processing your order may occur. FEE (All fees must be U.S. funds) • CERTIFIED COPIES OF A DEATH CERTIFICATE cost $15.00 for the first copy, $6.00 for each additional copy of the same record. (non-refundable) Please complete the following information. Decedent’s Name: Date of Death (We need a date to begin searching if date is unknown): of Birth: Place of Death: Place of Birth: Parents Names: Occupation: Spouse’s Name: Number of Copies Type of record needed? Certified Not Certified Reason record is needed Mailing or Delivery Address: Name: Address: City, State, Zip: Daytime Telephone Number: Signature of Applicant: Notary (For use if needed) Verification of Signer’s ID Is Mandatory State of County of This record was signed and sworn to (or affirmed) before me on by (Date) (Name of Signer) (Notary’s Signature) [Official Stamp] NOTICE: STATE LAW PROVIDES PENALTIES FOR PERSONS WHO WILLFULLY AND KNOWINGLY USES OR ATTEMPTS TO USE OR FURNISH TO ANOTHER FOR USE, FOR ANY PURPOSE OF DECEPTION, ANY CERTIFICATE, RECORD, REPORT, OR CERTIFIED COPY MADE, ALTERED, AMENDED, OR MUTILATED. (50-15-114(C), MCA) Official Use Only Date Rec# Amount Cert Ser Comment